On a fatal case of Candida krusei pleural empyema in a pregnant woman with spontaneous esophagus perforation.

INTRODUCTION: Candida empyema thoracis can be a consequence of operation, gastropleural fistula, and esophageal perforation. Case report and review of the literature. A fatal case of a 45-year-old pregnant woman with Candida krusei empyema thoracis secondary to spontaneous esophagus perforation associated with candida esophagitis is reported. The case is contextualized among similar cases found through a PubMed search. CONCLUSIONS: A suspect of esophagus rupture should arise in the presence of a fungal empyema. Candida esophagitis should be always considered as a possible cause or con-cause of esophagus rupture. An empirical systemic antimycotic therapy should always be considered in an ideal multidisciplinary approach to the management of patients with esophagus rupture.

Supra-acetabular brown tumor due to primary hyperparathyroidism associated with chronic renal failure.

A 63-year-old woman presented to the Orthopedic Unit of our hospital complaining of right hip pain of 6 months' duration associated with a worsening limp. Her past medical history included chronic renal insufficiency. Physical examination revealed deep pain in the iliac region and severe restriction of the right hip's articular function in the maximum degrees of range of motion. X-rays and CT scan detected an osteolytic and expansive lesion of the right supra-acetabular region with structural reabsorption of the right iliac wing. 99mTc-MDP whole-body bone scan showed an abnormal uptake in the right iliac region. Bone biopsy revealed an osteolytic lesion with multinucleated giant cells, indicating a brown tumor. Serum intact PTH was elevated (1020 pg/ml; normal values, 12-62 pg/ml), but her serum calcium was normal (total=9.4 mg/dl, nv 8.5-10.5; ionized=5.0 mg/dl, nv 4.2-5.4) due to the coexistence of chronic renal failure. 99mTc-MIBI scintigraphy revealed a single focus of sestamibi accumulation in the left retrosternal location, which turned out to be an intrathoracic parathyroid adenoma at surgical exploration. After surgical removal of the parathyroid adenoma, PTH levels decreased to 212 pg/ml. Three months after parathyroidectomy, the imaging studies showed complete recovery of the osteolytic lesion, thus avoiding any orthopedic surgery. This case is noteworthy because (1) primary hyperparathyroidism was not suspected due to the normocalcemia, likely attributable to the coexistence of chronic renal failure; and (2) it was associated with a brown tumor of unusual location (right supra-acetabular region).

Pneumomediastinum as a complication of critical pertussis.

BACKGROUND AND AIMS: Pertussis is a common and potentially serious disease affecting mainly infants and young children. In its non-classic presentation, pertussis can be clinically indistinguishable from other respiratory illnesses. Pertussis today often remains underdiagnosed in adults. Our aims was to report a complicated cases of pertussis. RESULTS: A case of serologically confirmed pertussis occurred in an 18-year-old man presenting with pneumomediastinum, subcutaneous emphysema in the neck and chest, and persistent attacks of coughing with apnea that required treatment in the intensive care unit. CONCLUSION: Pneumomediastinum and subcutaneous emphysema have never been described in adult patients with pertussis. Physicians should be aware that patients presenting with persistent cough and pneumomediastinum may have pertussis and include this in their differential diagnosis.

Isolated double orifice mitral valve in a young asymptomatic woman.

: Double orifice mitral valve (DOMV) is a rare congenital malformation of the mitral apparatus frequently associated with other congenital malformations of the heart, whereas the isolated form is rare. The prevalence is about 1% of congenital heart disease; valve stenosis and regurgitation are common findings. Echocardiography represents the best method to diagnose DOMV, providing both anatomical and functional data. We report a case of a young woman presenting with an isolated DOMV, in the absence of stenosis and significant regurgitation. The dysmorphic valve has been evaluated with both two-dimensional and three-dimensional echocardiography, providing impressive and detailed images of the peculiar anatomical configuration of the valve.

Intrathymic epidermoid cyst: a very rare condition.

A 65-year-old man presented with a nonspecific thymic neoplasm following blunt thoracic trauma. The lesion increased in size over 12 years, to reach 47 mm in diameter. After thymectomy, the lesion was described as an epidermoid lining cyst composed of thickened stratified squamous epithelium. We assume that this rare pathological condition was caused by skin tissue islands and fat migrating into the mediastinum.

The role of ultrasound-guided aspiration biopsy of peripheral pulmonary nodules: our experience.

BACKGROUND: Peripheral lung lesions are difficult to diagnose with conventional methods: ultrasound-guided aspiration biopsy is an interesting prospect having been reported to have good sensitivity and specificity. PATIENTS AND METHODS: From January 1991 to August 2001 we investigated, in 268 patients, the role of ultrasound-guided transthoracic fine needle aspiration for cytological diagnosis of peripheral lung lesions. Nodule sizes ranged from 1 to 10 cm. RESULTS: From 268 patients, we obtained 174 positive specimens for malignancy, of which 155 were positive for primary lung tumors and 19 for metastasis; 76 negative; 9 inadequate; and 9 aspecific. One patient developed pneumothorax after needle aspiration and one patient emophtoe. The nodule size did not affect complication rate and diagnostic outcome. CONCLUSION: This diagnostic procedure appears to be effective, safe and feasible, even in bedridden patients. The cost is low (70Euro), the examination is fast (5-6 minutes) and well-tolerated and, if the specimen is inadequate or non-specific, it is possible to repeat the examination. Ultrasound-guided aspiration biopsy can replace the TC-guided biopsy in patients with peripheral lung nodules.

Vitamins A, E, microelements and membrane lipid peroxidation in patients with neoplastic disease treated with calcium antagonists and antagonists of receptors H2.

We studied the serum levels of vitamins A, E, zinc and copper in two hundred and twenty-five subjects of both sexes. They were divided into two groups: 87 healthy subjects who served as controls and 138 patients with neoplastic disease. The patients were subdivided according to the absence (n = 79) or the presence of metastatic disease (n =59). In 59 patients with cancer, who were in therapy with scavenger drugs of free radical such as calcium antagonists and the antagonists of receptors H2, we also studied the possible effect of the same therapy on the serum levels of vitamins, on the concentrations of the microelements and on membrane lipid peroxidation. We found that membrane lipid peroxidation, evaluated from the time of in vitro formation in the blood of so-called "Heinz bodies," decreased in all patients treated with scavenger drugs. In these patients the permeability of the erythrocyte membrane was similar to the controls and the serum levels of the vitamins were equal to the levels in patients who did not receive these therapies. Zinc concentration increased while copper remained unchanged. We also studied the levels of vitamins in some organs. The results are discussed considering the role of free radicals. We underline the importance of vitamins A and E in the protection from membranous peroxidation and from free radicals and the need to consider cancer as a systemic morbid event, apart from the contingent actual location.

Chest wall reconstruction after resection in lung cancer: personal experience.

Chest wall reconstruction after resection, for locally advanced lung cancer but also for some selected secondary tumors, is a demanding challenge to surgeons, anesthetists and experts in respiratory function rehabilitation who must guarantee a regular natural ventilation, adequate protection of intrathoracic organs and acceptable cosmetic outcome. To this aim, many procedures using autologous, heterologous, or prosthetic materials, are available. A study conducted on 13 lung cancer patients who after resection underwent reconstruction with heterologous prosthetic material is presented. No intraoperative mortality or septic complications were observed. There was prompt wall stabilization in 10 patients; it occurred 3 weeks later in another patient (polytetrafluoridethylene patch). Only in one patient (prolene mesh) a seroma developed, treated with US-guided drainage. In the authors' experience, even for fairly small defects reconstruction with prosthetic material is suitable, to prevent, in case of the presence of risk factors, pulmonary hernia-induced major respiratory symptoms. Prosthetic materials are also preferred for benign lesions characterized by a long-term survival.

Parathyroid carcinoma as a challenging diagnosis: report of three cases.

Parathyroid carcinoma (PC) is a rare malignancy with an indolent but progressive course. This rare tumour is often difficult to diagnose preoperatively, thus limiting the efficacy of surgery. As long-term survival is largely dependent on the extent of the primary surgical resection, it is of great importance to consider PC in the differential diagnosis of hyperparathyroidism. We herein report three PC patients with different clinical histories who were followed up at our hospital for over a 5-year period, emphasizing the variability in clinical presentation of this rare tumour. Moreover, NORA (Nucleolar Organizer Regions, a standardised silver-stain, marker of proliferation rate) values encountered in these PC patients confirm that AgNOR analysis may be regarded as an additional tool when the pathologist encounters difficulties in defining parathyroid lesions which are not clearly benign.

Surgical management of pulmonary inflammatory pseudotumors: a single center experience.

BACKGROUND: The pulmonary inflammatory pseudotumor (PIP) is a rare disease. It is still debated whether it represents an inflammatory lesion characterized by uncontrolled cell growth or a true neoplasm. PIP is characterized by a cellular polymorphism. METHODS: We retrospectively analyzed 8 patients with PIP treated by surgery between 2001 and 2009. Preoperative thoracic computed tomography (CT) scan was performed in all cases. All patients underwent preoperative bronchoscopy with washing and brushing and/or transbronchial biopsy and preoperative cytology examination RESULTS: There were 5 men and 3 women, aged between 38 and 69 years (mean of 58 years). 3 patients (37%) were asymptomatic. The others had symptoms characterized by chest pain, shortness of breath and persistent cough or hemoptysis. 5 patients had neutrophilic leucocytosis. CT scan demonstrated solitary nodules (maximum diameter<3 cm) in 5 patients (62%) and lung masses (maximum diameter>3 cm) in 3 patients (37%). In 2 patients there were signs of pleural infiltration. Distant lesions were excluded in all cases. A preoperative histology examination failed to reach a definitive diagnosis in all patients. At surgery, we performed two lobectomies, one segmentectomy and five wedge resections, these being performed with videothoracoscopy (VATS), except for one patient where open surgery was used. Complete tumor resection was obtained in all patients. According to the Matsubara classification, there were 2 cases of organizing pneumonia, 5 cases of fibrous histiocytoma and one case of lymphoplasmacytoma. All patients were discharged alive from hospital between 4 and 7 days after surgery. At follow-up CT scan performed annually (range 11 to 112 months) (mean 58 months), there were no residual lesions, neither local nor distant recurrences. CONCLUSIONS: PIP is a rare disease. Many synonyms have been used for this disease, usually in relation to the most represented cell type. The true incidence is unclear. Preoperative diagnosis is difficult to reach, despite performing a bronchoscopy or a transparietal needle aspiration. Different classifications have been proposed for PIP. Either medical, radiation or surgical therapy has been used for PIP. Whenever possible, surgery should be considered the standard treatment. Complete surgical resection is advocated to prevent recurrence.

Giant endobronchial hamartoma resected by fiberoptic bronchoscopy electrosurgical snaring.

Less than 1% of lung neoplasms are represented by benign tumors. Among these, hamartomas are the most common with an incidence between 0.025% and 0.32%. In relation to the localization, hamartomas are divided into intraparenchymal and endobronchial.Clinical manifestation of an endobronchial hamartoma (EH) results from tracheobronchial obstruction or bleeding. Usually, EH localizes in large diameter bronchus. Endoscopic removal is usually recommended. Bronchotomy or parenchimal resection through thoracotomy should be reserved only for cases where the hamatoma cannot be approached through endoscopy, or when irreversible lung functional impairment occurred after prolonged airflow obstruction. Generally, when endoscopic approach is used, this is through rigid bronchoscopy, laser photocoagulation or mechanical resection. Here we present a giant EH occasionally diagnosed and treated by fiberoptic bronchoscopy electrosurgical snaring.

Thoracoscopic resection of a paraaortic bronchogenic cyst.

Bronchogenic mediastinal cysts (BMC) represent 18% of primitive mediastinal tumors and the most frequent cystic lesions in this area. Nowadays, BMC are usually treated by VATS. However, the presence of major adhesions to vital structures is often considered as an unfavourable condition for thoracoscopic treatment. The authors report the thoracoscopic treatment of a BMC having dense adhesions to the aortic arch. Diagnosis and surgical treatment is described. Review of the literature and surgical options on this topic are discussed.

Phagocytosis of cancer cells by mast cells in breast cancer.

BACKGROUND: Mast cells (MCs) remain enigmatic more than 100 years after their discovery by Paul Ehrlich. Continuous research over the last 20 years has finally characterized the origin of MCs and determined many of the factors involved in MC differentiation and proliferation. MCs are traditionally known for mediating allergic reactions. In addition, these cells have been implicated in the pathogenesis of clinical conditions. Studies on the role of MCs in cancer have given contrasting results. MATERIALS AND METHODS: This study included 50 cases of invasive ductal breast cancer not otherwise specified (NOS): 25 of them were highly hormone-receptive (HHR) cancers with estrogen and progesterone receptor values not lower than 50%, 25 were minimally hormone-receptive (MHR) cancers (<5%). In both groups, mast cells were quantified in the peritumoral area. Twenty cases of surgical interventions without cancer were included as controls. RESULTS: It was found that in infiltrating ductal breast cancers having a high hormone receptor content (>50% for both estrogen and progesterone), there was a highly significant increase in MCs with respect to hypo-hormonal cancers in the same location and to controls (p<0.0001). MCs have thus proven to be very important cells because they have been found in sites playing an active role in opposing the aggression of the cancer cells (CCs). MCs may represent a protective factor of the human body against cancer aggresion. Two biological phenomena with the same goal can be observed: CCs are first phagocytized by MCs and then completely destroyed by karyocytoplasmic chemolysis through the action of toxicophore granulations. It was demonstrated that one or more CCs are surrounded by an MC's pseudopodia and then engulfed in its cytoplasm. The phagocytized cell progressively loses its chromatic and volumetric characteristics until complete achromia and almost complete reduction of its volume and consistency occur. The cell nucleus soon degenerates to pyknosis and becomes no longer detectable.

Spontaneous pneumomediastinum: experience in 18 adult patients.

Spontaneous pneumomediastinum (SPM) is defined as the presence of air in the mediastinum, developing in the absence of traumatic, iatrogenic, or preceding pulmonary pathologies (emphysema, chronic bronchitis, and lung cancer). The aim of this study was to review our experiences with SPM, underlining its symptomatology, diagnosis, treatment, and followup, and defining a reasonable course of assessment and management. A retrospective case series was conducted to identify adult patients with SPM who were diagnosed and treated in our institution between 1998 and 2005. Eighteen patients (10 males) were identified (average age = 25 +/- 4.8 years). Acute onset of chest pain was the predominant symptom at presentation. All patients developed clinically evident subcutaneous emphysema and underwent chest computerized tomography. Fiber bronchoscopy and echocardiogram were used selectively (8 patients). The average hospital stay was 6 (+/-1.4) days. Sixteen patients were conservatively treated, and only two patients were treated with thoracic drainage due to a related pneumothorax. The disease followed a benign evolution in all patients and, as of today, no relapse has been reported. SPM is an uncommon pathology with a usually benign course. The authors discuss SPM. A diagnostic algorithmic approach is necessary to rule out severe secondary entities and consequences that need urgent treatment.